On this page:
- What are System Level and Contributory Measures?
- What are the current System Level Measures?
- Are there any plans to change or add to the current System Level Measures?
- How were the System Level Measures developed?
- How are System Level Measures implemented?
- What is a district alliance?
- Can regional alliances develop and submit Improvement Plan on behalf of their health system partners?
- What is required in the Improvement Plan?
- What are the targets for the System Level Measures?
- What is the Ministry looking for when assessing and approving the Improvement Plan?
- Can I use measures not listed in the Measures Library as contributory to System Level Measures?
- What is required for quarterly reporting?
- Do the alliances need to report on contributory measures to the Ministry?
- What will happen to the $23 million incentive pool available for the PHOs?
- What is the 75% capacity and capability payment for?
- Will the incentives be linked to performance?
- How will PHOs be paid?
- What happens to performance payment three if the alliance has not met the improvement milestone? Will PHOs still get paid?
- What happens to the national health targets?
- Who can I speak to for more details?
System Level Measures are outcome focused measures that provide a framework for continuous quality improvement and system integration. These are set nationally and focus on children, youth and vulnerable populations. System Level Measures aim to improve health outcomes for people by supporting DHBs to work in collaboration with health system partners (primary, community and hospital).
Contributory measures assist in the achievement of the System Level Measures, and are chosen locally by district alliances based on local needs, demographics and service configurations. These are used to measure local progress against quality improvement activities.
All measures are held in an online Measures Library available on Health Quality Measures New Zealand.
There are six System Level Measures:
- Ambulatory Sensitive Hospitalisation (ASH) rates for 0–4 year olds (keeping children out of hospital)
- acute hospital bed days per capita (using health resources effectively)
- patient experience of care (person-centred care)
- amenable mortality rates (prevention and early detection)
- babies living in smokefree homes (a healthy start)
- youth access to and utilisation of youth appropriate health services (youth are healthy, safe and supported).
At this stage there are no plans to change or add to the current six System Level Measures.
The six System Level Measures are the result of a clinically led co-design process over several months. They evolved from an initial list of over 100 measures. A core group for measures development, including 14 sector clinicians from primary and secondary care have been key to measure development and selection. Widespread discussion with clinicians and managers has also supported this work, including meetings with Primary Health Organisation (PHO) Clinical Governance Groups and DHB alliance leadership teams. There was consultation with 32 groups between July and October 2015 alone.
District alliances are responsible for implementing the SLMs in their districts. District alliances are responsible for:
- harnessing perspectives from all relevant parts of the health system to identify shared vision and key objectives for their districts
- applying alliancing principles (way of working)
- using SLMs to drive system integration in their districts
- leading the development, implementation and monitoring of the SLM Improvement Plan in their districts
- allocating resources required for the development, implementation, monitoring and reporting of the SLMs.
District alliances are local leadership teams. They are clinically led groups that use a joint decision making approach to system integration and service planning. Membership includes the DHB of domicile and at the minimum, all the PHOs providing health services to the population of that district. DHBs are expected to take the lead in progressing alliance lead activity.
All DHBs are expected to form an alliance that includes all the appropriate health system partners (primary, community and hospital) in their district (as per the PHO Services Agreement and the DHB Annual Plan requirements).
Form and function of alliances vary across the country with some being a partnership of the DHB of domicile and its PHOs only. Others have much broader alliance partners that include consumers, ambulance, pharmacy, midwives, Well Child Tamariki Ora providers, public health units etc.
System Level Measures recognise that good health outcomes require health system partners to work together. Therefore it is envisaged that all district alliances will overtime have a whole of system focus, develop local relationships and trust between health system partners in their district and have a clear focus on delivery of integrated care by placing their population and patient at the centre at all times.
Can regional alliances develop and submit Improvement Plan on behalf of their health system partners?
DHBs in a region may choose to plan, develop and implement SLMs together especially in places where there are multiple PHOs providing services across DHB boundaries. However, the Improvement Plan must show how each DHB is targeting the improvement based on the population needs, demographics and service configurations of their DHB district.
One such example is how the three DHBs and seven PHOs in metro-Auckland have developed their Improvement Plan. Planning and development are regional but activities are targeted to the specific demographics of each DHB. Their approach and plan can be found on the Nationwide Service Framework Library.
All district alliances are required to submit an Improvement Plan to the Ministry showing how the alliance is implementing the SLMs in their district. The Improvement Plan must include:
- an improvement milestone for each of the six SLMs, which is a number that improves performance from baseline for either total population, Māori or other vulnerable population group. If there is an equity gap the milestone must reduce this gap.
- a brief description of activities to be undertaken by alliance partners to achieve the milestone
- a list of contributory measures, clear line of sight to each SLM, that will be used to track local progress
- signatures of all alliance partners to demonstrate partnership approach.
DHBs are responsible for submitting the SLM Improvement Plan on behalf of their district alliance as part of the annual planning process. The Ministry assesses and approve the Improvement Plans.
All alliances are expected to have a more detailed local improvement/project plan that explains how the district will achieve their improvement milestones. The local improvement/project plan does not have to be submitted nationally but will be made available to the Ministry on request.
Examples of Improvement Plans are available on the Nationwide Service Framework Library.
There are no national targets for the System Level Measures.
The improvement milestone for each System Level Measure is determined by the district alliance based on their baseline and trend data. This data is provided by the Ministry of Health on the Nationwide Service Framework Library.
The improvement milestone will be an appropriate number that improves performance from baseline for either total population, Māori or other vulnerable population group. Improvement milestones must address equity gaps.
The improvement milestones are approved by the Ministry of Health.
Assessment of the Improvement Plan will include a review of the following:
- How the district alliance has used an integrated and partnership approach with their health system partners to develop the Improvement Plan. All the partners’ signatures are required to demonstrate their commitment to joint responsibility for implementation of the Plan.
- The improvement milestone, for each System Level Measure is:
- based on the district’s trend and baseline data
- a number that improves performance from baseline
- addressing inequalities for Māori, Pacific and other population groups with significant health disparities
- determined through the use of health information tools and improvement science methods.
- The quality improvement activities:
- are action focused and achievable in one year
- will contribute to the achievement of the improvement milestone
- reflect the integrated approach across the health system
- reflect the health investment needed based on local population needs, demographics and service configurations
- have been selected based on health information tools and improvement science methods.
- The contributory measures chosen:
- are based on available and reliable data
- are measurable with defined numerator and denominator
- are chosen from the Measures Library
- have a clear line of sight to the improvement milestone and quality improvement activities.
Districts should refer to the Measures Library first for contributory measures. However if the contributory measures available in the Library are not suitable, districts may choose to use other measures that are clearly defined (including a numerator and denominator), have been piloted and validated and that contribute to the System Level Measures.
In the spirit of collaboration, the expectation is that if a district has a contributory measure that supports progress towards the System Level Measures that is not in the library, they submit it for inclusion in the Library, so it can be shared with other districts.
DHBs are responsible for submitting the quarterly reports on behalf of their district alliance, as part of the quarterly reporting process, through the DHB quarterly reporting database.
Quarters one, two and three – the alliance will report whether they are on track with the implementation of their Improvement Plan. If the alliance is not on track, the report will include mitigation plans to get back on track. This may include changes to their Improvement Plan, in agreement with the Ministry. These reports will be assessed by the Ministry and feedback provided via the DHB quarterly reporting database.
Quarter four – performance against the implementation of the Improvement Plan and whether the improvement milestone was achieved by the alliance. If the Improvement Plan was not fully implemented and/or the milestone was not achieved, the report should include clear and reflective thinking from the alliance on how the Improvement Plan was developed and implemented, reasons for not implementing the plan or achieving the milestone and learnings from the year that will be used for development and implementation of following year’s Plan.
Reporting templates are available on the Nationwide Service Framework Library.
The Ministry does not require reporting on the contributory measures. These should be used by the district alliance to measure local progress of the quality improvement activities in the plan.
The $23 million PHO incentive pool (that was previously used to incentivise the five Integrated and Performance Incentive Framework targets) is largely now used to build capacity and capability in primary care for implementation of the System Level Measures and the two primary care national health targets. A small proportion of the funding pool is based on performance.
Two capacity and capability payments and one ‘at risk’ performance payment is paid to PHOs:
- Payment one: 25% capacity and capability payment up front in quarter one (15 July)
- Payment two: 50% capacity and capability payment in quarter one once the Ministry approves the district alliance’s Improvement Plan (15 September)
- Payment three: 25% performance payment based on quarter four performance (15 September following end of financial year).
The 75% capacity and capability payment is to build quality improvement and analytic capacity and capability in primary care that may include clinical and non-clinical infrastructure eg building ’continuous quality improvement’ competencies and culture, implementation of primary care patient experience survey, improving information technology and analytics, enabling clinical leadership and outreach services.
At least 50% of the funding must have direct financial benefit to general practice.
Payment three, the last 25% performance payment is paid to the PHOs based on quarter four performance of the following three System Level Measures and two primary care national health targets:
- ASH rates for zero to four year olds
- Acute hospital bed days per capita
- Patient experience of care
- national health target Better help for smokers to quit
- national health target Increased immunisation for eight-month olds.
The payments will be made to the PHOs through their contracted DHB as per current processes.
What happens to performance payment three if the alliance has not met the improvement milestone? Will PHOs still get paid?
The aim of SLMs is to support the integration of the health system and to improve population health outcomes by using quality improvement science to appropriately target health investment to Māori and those population groups that consistently experience poor health outcomes. If the district has not achieved the improvement milestone(s) but had a Ministry approved Improvement Plan that was fully implemented by all alliance partners, it is still possible for PHOs to receive the performance payment.
Decision for this payment is made by the Ministry based on the quarter four report from the district alliance. This takes into consideration the following:
- maturity of alliances
- clinical leadership and engagement
- focus on patient experience and safety
- use of quality improvement science and tools
- use of commissioning to target investment.
The national health targets will continue in their current form, including the requirements to meet the national target and report quarterly.